176078 08/18/2009 CITY OF CARMEL, INDIANA VENDOR: 360618 Page 9 of 1
ONE CIVIC SQUARE STEPHANIE MARSHALL
CARMEL, INDIANA 46032 578 TULIP POPPLUR CREST CHECK AMOUNT: $199.11
CARMEL IN 45033 CHECK NUMBER: 176078
CHECK DATE: 8118/2009
DEPARTMENT ACCOUNT PO N UMBER INVOICE NUMBE AM OUNT DESCRIPTION
902 4347500 199.11 COBRA
r
Richard Marshall, Jr. SVP Worldwide COBRA Coupon #1 May /2009
Coverage Tier Period Premium
BCBS HDHP /HSA Medical Plan Employee Family 05/02/2009 05131/2009 300.66
Delta Dental Plan Employee Family 05102J2009 05/3112009 21.99
Comments 1 Notes: Subtotal: $322.65
Amount Paid: S0.00
l Return this Coupon and Your Payment to: Coverage for: Total Due: $322.65
Medcom Richard Marshall. Jr. Due Date: 05/01/2009
P.O. Box 10269 Total Enclosed:
Jacksonville, FL 32247 -0269 578 Tulip Poplar Crest
Carmel, IN 46033 Make Check Payable to:
Medcom
l�I�n 1�... LJ..... --A 0..4........1 {.k V... i.
i
T- pree AulomafedBariklme (800) 565 3512
B VB Personal Banker (800) 357 6246 lam =9pm CST; M F
Nalionzl l.eac.'er nr hlcalrh .Sauin,Gs �rcuulr rs. Fax: (877) 8517041
A Division of Webster Bank,N.A, Internet Banking wwwsabank com
P.O. Box 939 Mail: HSA Bank 695 N' Sth Streef, Sude 320; Sheboygan WI 53081
Sheboygan, WI 53082 -0939 a -mad askus @hsabi -66
Para un reprasentanYe en espanol por favor Ilamar al 8fi6 357 &232
Richard C Marshall dr 7 N
1$90?I706
t 578 Tulip Poplar Crest
Carmel, IN 46033
r t5 1
;4 +Y ancm5,M .Y r �r;� 'h
$8:77:, -4 24
Hsa HSa 13X NK
Neiinuaf t,�udr:r in lfcaiiL Sarh,u; rinruwils, Y,; rin:rl f -order i;: Hr,rllh 5•r. vri;o :l e.nurls.
-,Y ,-:DzrC Yltl nx awu fi,_s r v r�ebltS' �r rvs Cie(�1tS; "'iDB�C a r�i x 4x ��d�BiICeM.� �y�•
BALANCE LAST STATEMENT 05/31/2009 6,337.14
FEE 7.95 06/15/2009 6,329.19
CHECK PRINTING FEE
DISTRIBUTIONfWITHDRAWAL 62.00 06/24/2009 6,267.19
0/758486 N1 INUTECLINIC \4• NINE 612- 650 -7911 INN
DISTRIBUTION/WiTHDRAWAL 663.30 06/25/2009 5,603.89
76504043 90 <i 505224,6 R
DiSTRIBUTIONIWITHDRAWAL 260.99 06/26/2009 5,342.90
'13 7 63921 CVS PFi1YRiviACY :'•A,5:5I,, C: t -L IN
INTEREST PAID 8.77 06/30/2009 5,351.67
I
ANNUAL PERCENTAGE YIELD EARNED FOR 30 DAYS IS 1.75%
INTEREST•EARNED DURING CYCLE PERIOD 8.77
CURRENT RATE ,1.73%
AVERAGE BALANCE FOR THIS STATEMENT CYCLE; $6 28
13A N K NSA BankGJ is a division of Webster Bank, N.A., Member FDIC
SVP Worldwide
ARRA Notice
COBRA PREMIUM REDUCTION COMPUTATION FORM
Important Information for Assistance Eligible lndiAduals who have elected the Premium Reduction: Your premium for
coverage periods beginning prior to February 17, 2009 will be at the Full Premium Rate. For coverage periods beginning on or after
February 17, 2009, premiums will be calculated at the Premium Assistance Rat&; until you are no longer eligible for the reduced
premium.
1
BCBS HDHP/HSA Medical Plan
Reduced Tier Rates: �2 u 3 ie..
Employee Only mployee Fami ly l� N i I v_'
S
125.70
Delta Dental Plan
Reduced Tier Rates:
Employee Only mplayee i Family 5p CC77"
7.91 2 2.72 o f 8 Cl
C` Lj
Pa 7 of 7
Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
Purchase Order No.
5 7 8 Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
0 S'o /o 050/o9
l
1 4
Le
y.
Total
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance
with IC 5- 11- 10 -1.6. =,�0
20
Clerk- Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN SUM OF
ON ACCOUNT OF APPROPRIATION FOR
9,7 /y 3 ?5Z-IL)
Board Members
PO# or DEPT. INVOICE NO. ACCT #!TITLE AMOUNT 1 hereby certify that the attached invoice(s), or
902 0 5 d 1 e�9 a bill(s) is (are) true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
B 20 0
S r l Wjr a fil oins
Director o
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund